Patient Case Study
Kelly is a 35-year-old female who came to our clinic looking for answers and to help deal with her dizziness symptoms. Symptoms started 3 years ago with an episode of vertigo. Though her vertigo is no longer present, over the years she has been experiencing a progressively worsening constant rocking and swaying sensation. As a result, she has been avoiding activity and household chores. Tasks such as driving, going to the grocery store, and being on the computer have progressively gotten more challenging. As a result, she has been unable to continue working as an Accountant. Neck pain has been increasing due to head movement avoidance and headaches have been a more common reoccurrence. She was seen by various Doctors and Physical Therapists who prescribed Epley maneuvers for BPPV and Antivert medications which made no change to symptoms. Diagnostic workups such as MRI, EKG, Blood work, audiogram, and VNG were all normal. She became frustrated as she felt these symptoms worsening but testing was not indicating that something was the cause.
Kelly was then seen by an ENT who specializes in dizziness and vertigo and was diagnosed with Persistent Postural-Perceptual Dizziness (PPPD). During her evaluation, when I explained to her what that diagnosis entailed, she broke down crying as she finally felt that someone understood her symptoms. As a Vestibular Therapist, PPPD is a common condition that I treat. However, it is not as widely known in the medical community and is often not heard of, overlooked, and/or diagnosed and treated incorrectly. With Vestibular Physical Therapy, medication, and symptom management, she was able to reduce symptoms and return to work. Let’s discuss further what PPPD is and how it is treated effectively.
3 Balance Systems
Before discussing what PPPD is, it is important to first understand the different components of our balance system. Our brain utilizes three different balance systems:
Vision: utilization of our eyes to provide feedback
Somatosensory: our joints and muscles send signals of our body position
Vestibular: the inner ear has sensors that are sensitive to motion and position of the head.
** Check our blog post on the 3 balance systems for a more in-depth review.
What is PPPD?
Persistent Postural-Perceptual Dizziness (PPPD) is defined as a chronic functional neurologic disorder that is characterized by a non-spinning vertigo and unsteadiness. PPPD is a newly defined diagnosis that had been updated from its former names of Phobic Postural Vertigo (PPV) and Chronic Subjective Dizziness (CSD). In 2014, a diagnostic criterion was created by the Bárány Society to help with diagnosis of Persistent Postural-Perceptual Dizziness (see below).
PPPD is thought to be a clinical diagnosis indicating that doctors will diagnosis based on medical signs and reported symptoms rather than diagnostic testing. Exams, laboratory bloodwork, and imaging cannot be used to diagnose a patient with PPPD as they can commonly present with normal findings. These tests are instead used to determine any secondary diagnoses that may contribute to a PPPD diagnosis and rule out any other diagnoses.
What causes PPPD?
The exact pathophysiology and cause of PPPD is still being researched. Though, researchers believe that the condition progresses due to a concept called Neuroplasticity. Neuroplasticity is the brain’s ability to adapt and change both structure and function when you experience different stressors in life. For example, say you drove for the first time to get to the grocery store. Your brain learns and you remember this route to the store. With Neuroplasticity, there is a concept called adaptation and maladaptation. Referring to our previous example, say you learned a quicker route to get to the grocery store, you then adapt your strategies to get to the store and begin taking this faster route. However, say you are taking that route and end up getting in a car accident. Following that accident, you are now fearful to take that same route. As a result, you have this maladaptive practice in which you now take a much longer route to the store to avoid that road.
The diagram below by Staab et al. clarifies how PPPD develops.
PPPD will occur following an initial vestibular event, such as a vestibular crisis, medical event, or psychological event. Examples of an initial event are BPPV, Stroke, MAV or even panic attacks. Following the event, our bodies act accordingly, and we begin an acute adaptation phase where we can highly rely on the visual and somatosensory systems if there is a dysfunction of the vestibular system and we become guarded of things that might increase our symptoms. Following, we should see recovery from the event in which we would no longer have symptoms. However, with PPPD we instead get failure of adaptation and symptoms of increased dizziness will occur. Patients may experience increased symptoms in upright posture, self-motion or that the environment is moving, and can become visually dependent in which you rely heavily on just the visual system to keep you balanced instead of utilizing all 3 systems equally. Predisposing factors such as anxiety and depression can contribute to the perpetuating loop that results with PPPD.
SYMPTOMS & CLINICAL PRESENTATION
Patients with PPPD will present with various reports of severity, intensity, and duration of dizziness and imbalance and each case will be individualized. In addition to dizziness and imbalance, other symptoms may persist. Hypersensitivity to vestibular stimulation, such as head and body movement or upright posturing can occur. Common physical presentations include movement avoidance behavior patterns, disassociation of head and body movements, and gait dysfunction. Cognitive behavioral responses such as anxiety, phobias, depression, and stress can contribute to symptoms.
Visual dependency as stated earlier can exacerbate symptoms when in complex visual environments, such as driving, computer usage, viewing patterns, and grocery shopping. This results as patients tend to over-rely on the visual system for postural and visual control with poor utilization of the vestibular and somatosensory systems. PPPD is a functional diagnosis indicating that daily activities, such as work and household chores, will be impacted and possibly become debilitating. Symptoms and ability to perform functional tasks will vary between individuals. Everyone will report differences in severity, intensity, and duration of dizziness and imbalance.
CLINICIAN REFERRAL
PPPD diagnoses can involve multidisciplinary care due to possible involvement of vestibular system, brain, hearing, and psychological components. Patients may benefit from a referral to the following for further evaluation and treatment:
· Ear Nose and Throat (ENT)
· Neurologist
· Audiologist
· Psychologist/Psychiatrist
· Ophthalmologist and/or Neuro-ophthalmologist
· Physical Therapist
TREATMENT OPTIONS
1. VESTIBULAR REHABILITATION THERAPY
If diagnosed with PPPD by a Medical Doctor, Vestibular Rehabilitation Therapy (VRT) may be appropriate for your recovery. A trained Vestibular Physical Therapist will perform various tests using advanced diagnostic tools and specialized equipment to better identify impairments. Each treatment plan will be individualized to each person, as patients can present with various severities and dysfunctions. VRT treatments may include the following:
Cervical Manuals
Soft tissue and joint mobilization to assist with reducing muscle tension and guarding to improve head from body dissociation and posture. Assists with reducing occurrence of headache and migraine symptoms.
Habituation Exercises
Exercise that is designed to reduce sensitivity to specific movements through repeated exposure to stimuli.
Visual Desensitization/Optokinetic Training
Reduce overreliance of the visual system for patients with difficulty in visually complex environments (such as driving, computer/phone usage, grocery shopping) with recalibration of the 3 balance systems.
Gaze Stabilization/VOR
Exercises that assist with improving vestibular dysfunction by improving the gain of the Vestibular Ocular Reflex (VOR).
Balance Training
Address deficits in strength, proximal control, balance reaction and utilization of balance systems to improve balance and safety with walking and functional activities.
Symptom Management Techniques
Education in recognizing dizziness triggers and prevention of reaching symptom thresholds through guided activity pacing and techniques to control symptoms.
2. COGNITIVE BEHAVIORAL THERAPY
Psychological conditions such as anxiety, stress, panic attacks, and agoraphobia are common comorbidities of PPPD. Cognitive Behavioral Therapy (CBT) performed by a licensed psychologist or psychiatrist can provide treatment to address such conditions.
3. MEDICATION
There is no specific medication that has been developed to treat PPPD. However, some medications, such as SSRI/SNRI’s, have been found to assist with dizziness symptoms or can be used to help treat comorbidities, such as migraines/headaches. For medication treatment, speak with a medical doctor who specializes in treatment of vestibular dysfunctions.
CONCLUSION
If you suffer from Persistent Postural-Perceptual Dizziness, there is research guided treatment that is available. At Ascend Physical Therapy, we specialize in the treatment and management of PPPD symptoms. We work closely with your doctors to find the best course of action to reduce your symptoms and improve your quality of life. Physical Therapy interventions are designed specifically to each patient based on their individual symptoms and goals. If you suffer from dizziness or vertigo, we are here to help!
References
Popkirov S., Staab JP, and Stone J, Persistent postural- perceptual dizziness (PPPD): a common, characteristic, and treatable cause of chronic dizziness, Practical Neurology (2018), 5–13.
Staab JP, A. Eckhardt-Henn, A. Horii, R. Jacob, M. Strupp, T. Brandt and A. Bronstein, Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the committee for the classification of vestibular disorders of the ba ́ra ́ny society, Journal of Vestibular Research 27 (2017), 191–208.
Staab JP. Persistent Postural-Perceptual Dizziness. Semin Neurol 2020; 40(01): 130-137
Author: Dr. Genevieve Neely, PT, DPT
Dr. Genevieve Neely, PT, DPT received her Bachelor of Science degree from California State University, Fullerton in Kinesiology graduating Magna Cum Laude. She received her Doctorate in Physical Therapy from California State University, Long Beach receiving the Kishan Kooner scholarship for academics. She has clinical experience at various neurologic and orthopedic settings with a special interest in neurologic, vestibular, and balance disorders. Her treatment philosophy involves providing the utmost care that promotes healing. Each individual receives specialized treatments to reach their personal goals and maximize their overall quality of life. Genevieve is inspired by the positive impact that physical therapy can provide her patients and enjoys helping each patient reach their maximal function. Outside of work, she enjoys playing softball and spending time with her family and dog.
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